Emergency Radiology

Correction to: Spectrum of diagnostic errors in cervical spine trauma imaging and their clinical significance The published version of this article unfortunately contained a mistake. Author given and family name Alessandrino Francesco was incorrectly interchanged. The correct presentation is given above. The original article has been corrected.

Core curriculum illustration: supination-external rotation trimalleolar fracture Abstract This is the 37th installment of a series that will highlight one case per publication issue from the bank of cases available online as part of the American Society of Emergency Radiology (ASER) educational resources. Our goal is to generate more interest in and on the use of our online materials. To view more cases online, please visit the ASER Core Curriculum and Recommendations for Study online at http://www.erad.org/page/CCIP_TOC.

Core curriculum illustration: pediatric buckle fracture of the distal radius Abstract This is the 38th installment of a series that will highlight one case per publication issue from the bank of cases available online as part of the American Society of Emergency Radiology (ASER) educational resources. Our goal is to generate more interest in and use of our online materials. To view more cases online, please visit the ASER Core Curriculum and Recommendations for Study online at: http://www.erad.org/page/CCIP_TOC

Accessory ossicles of the foot—an imaging conundrum Abstract Various anatomical variations can be found in the foot and ankle, including sesamoid bones and accessory ossicles. These are usually incidental findings and remain asymptomatic; however, they may cause complications resulting in painful syndromes or degenerative changes secondary to overuse or trauma. They can also lead to fractures or simulate fractures. These complications are challenging to diagnose on radiographs. Advanced imaging with US, CT, MRI, or Tc-99m bone scan is useful for definitive diagnosis. This study aims to illustrate how imaging modalities can be used to diagnose complications of common sesamoids and accessory ossicles of the ankle and foot (hallux sesamoids, os trigonum, accessory navicular, os supranaviculare, os peroneum, os intermetatarseum, and os calcaneus secundarius) and demonstrate the imaging differences between fractures and their mimics.

Characterization of all-terrain vehicle–related chest injury patterns in children Abstract Purpose To evaluate chest injury patterns in pediatric patients involved in all-terrain vehicle (ATV) accidents. Methods Retrospective review of patients 0–18 years old admitted to a level I trauma institute following an ATV-related incident from 2004 to 2013 was performed. Chest injury type, accident mechanism, driver/passenger status, and demographic and clinical data were compared between patients with and without chest injury. Results Chest injury was present in 102 (22%) of total 455 patients. The most common chest injuries were pulmonary contusion (61%), pneumothorax (45%), and rib fracture (34%). There were no cardiac, esophageal, or tracheobronchial injuries. Pulmonary lacerations, hemothoraces, and scapular fractures were predominantly not detected on radiography and recognized on CT only (86–92%). Patients with chest injury had longer median hospital stays (3 days vs 2 days, p = 0.0054). There was no significant difference in admission to intensive care after controlling for injury severity scores in patients with chest injury compared to those without (17 vs 9). Eight patients with chest injury died (8%) compared to 2 patients without chest injury (0.6%) (p = 0.0002). Conclusions Chest injuries are common in children following ATV accidents and may be a marker of more severe trauma. Increased public awareness of these potentially devastating injuries and continuing safety efforts are needed.

The cost of callbacks: return visits for diagnostic imaging discrepancies in a pediatric emergency department Abstract Purpose Diagnostic imaging has mirrored the steady growth of healthcare utilization in the USA. This has created greater opportunity for diagnostic errors, which can be costly in terms of morbidity and mortality as well as dollars and cents. The purposes of this study were to describe all return visits to a tertiary care urban pediatric emergency department (PED) resulting from diagnostic imaging discrepancies and to calculate the costs of these return visits. Methods From July 2014 to February 2015, all children who underwent a diagnostic imaging study during an ED visit were assembled. Analysis was performed on all children who were called back and returned to the ED following a discrepant read. Direct and indirect costs to the patient, family, hospital, and society for these return visits were calculated. Results During the study period, 8310 diagnostic imaging studies were performed, with 207 (2.5%) discrepant reads. Among the discrepant reads, 37 (0.4% of total, 17.9% of discrepant) patients had a return visit to the ED for further management. Including ED charges, time and travel costs to the family, and costs of radiation exposure, return visits for radiologic discrepancies over this 8-month period cost a total of $84,686.47, averaging $2288.82 per patient. Conclusions Though the overall diagnostic imaging discrepancy rate among our study population was low, the clinically significant discrepancies requiring return ED visits were potentially high risk, and costly for the patient, family, and healthcare system.

Dismantling the ability of CT and MRI to identify the target mismatch profile in patients with anterior circulation large vessel occlusion beyond six hours from symptom onset Abstract Purpose Patients with large vessel occlusion and target mismatch on imaging may be thrombectomy candidates in the extended time window. However, the ability of imaging modalities including non-contrast CT Alberta Stroke Program Early Computed Tomographic Scoring (CT ASPECTS), CT angiography collateral score (CTA-CS), diffusion-weighted MRI ASPECTS (DWI ASPECTS), DWI lesion volume, and DWI volume with clinical deficit (DWI + NIHSS), to identify mismatch is unknown. Methods We defined target mismatch as core infarct (DWI volume) of < 70 mL, mismatch volume (tissue with TMax > 6 s) of ≥ 15 mL, and mismatch ratio of ≥ 1.8. Using experimental dismantling design, ability to identify this profile was determined for each imaging modality independently (phase 1) and then with knowledge from preceding modalities (phase 2). We used a generalized mixed model assuming binary distribution with PROC GLIMMIX/SAS for analysis. Results We identified 32 patients with anterior circulation occlusions, presenting > 6 h from symptom onset, with National Institute of Health Stroke Scale of ≥ 6, who had CT and MR before thrombectomy. Sensitivities for identifying target mismatch increased modestly from 88% for NCCT to 91% with the addition of CTA-CS, and up to 100% for all MR-based modalities. Significant gains in specificity were observed from successive tests (29, 19, and 16% increase for DWI ASPECTS, DWI volume, and DWI + NIHSS, respectively). Conclusions The combination of NCCT ASPECTS and CTA-CS has high sensitivity for identifying the target mismatch in the extended time window. However, there are gains in specificity with MRI-based imaging, potentially identifying treatment candidates who may have been excluded based on CT imaging alone.

Augmenting Denver criteria yields increased BCVI detection, with screening showing markedly increased risk for subsequent ischemic stroke Abstract Purpose BCVI may lead to ischemic stroke, disability, and death, while being often initially clinically silent. Screening criteria for BCVI based on clinical findings and trauma mechanism have improved detection, with Denver criteria being most common. Up to 30% of patients do not meet BCVI screening criteria. The aim of this study was to analyze the effect of augmented Denver criteria on detection, and to determine the relative risk for ischemic stroke. Methods Denver screening criteria were augmented by any high-energy trauma of the cervical spine, thorax, abdomen, or pelvis. All acute blunt trauma WBCT including CT angiography (CTA) over a period of 38 months were reviewed retrospectively by two Fellowship-trained radiologists, as well as any cerebral imaging after the initial trauma. Results 1544 WBCT studies included 374 CTA (m/f = 271/103; mean age 41.5 years). Most common mechanisms of injury were MVA (51.5%) and fall from a height (22.3%). We found 72 BCVI in 56 patients (15.0%), with 13 (23.2%) multiple lesions. The ICA was affected in 49 (68.1%) and the vertebral artery in 23 (31.9%) of cases. The most common injury level was C2, with Biffl grades I and II most common in ICA, and II and IV in VA. Interobserver agreement was substantial (Kappa = 0.674). Of 215 patients imaged, 16.1% with BCVI and 1.9% of the remaining cases had cerebral ischemic stroke (p < .0001; OR = 9.77; 95% CI 3.3–28.7). Eleven percent of patients with BCVI would not have met standard screening criteria. Conclusions The increase in detection rate for BCVI justifies more liberal screening protocols.

There has to be an easier way: facet fracture characteristics that reliably differentiate AOSpine F1 and F2 injuries Abstract Purpose To identify morphologic features of isolated cervical spine facet fractures that can reliably differentiate AOSpine F1 and F2 injuries. Materials and methods Retrospective review of cervical spine CTs on all patients who sustained isolated cervical fractures of the facets presenting to our level 1 trauma center from August 2012 through December 2015. CTs were reviewed for facet fracture characteristics and AOSpine facet fracture classification. Association between facet fracture characteristics and AOSpine classification was assessed through multivariable logistic regression models. Results Fifty-six patients with cervical spine fractures isolated to the facets were included in the study. The mean age was 36 (range 9–90) years with 55.4% (n = 31) males. A significant correlation was found between subtype F1 and subtype F2 in laterality (left- or right-sided) (p = 0.004), interfacetal fracture involvement (p < 0.0001), transverse process involvement (p < 0.001), displacement of fracture fragment (p < 0.001), comminution of fracture (p < 0.0001), and vertebral arch disruption (p = 0.001). After multivariable analysis, left side laterality (p = 0.03), transverse process involvement (p = 0.01), and fracture comminution (p = 0.003) were associated with F2 fractures. Conclusion Facet fractures with transverse process involvement or comminution have a higher probability of being an F2 fracture. These characteristics may be helpful when categorizing facet fractures using the AOSpine classification.

Accuracy and timeliness of an abbreviated emergency department MRCP protocol for choledocholithiasis Abstract Purpose To determine the diagnostic accuracy and time savings of an abbreviated magnetic resonance cholangiopancreatography (A-MRCP) protocol for detecting choledocholithiasis in patients visiting the emergency department (ED) for suspected biliary obstruction. Methods and materials This retrospective study evaluated adult patients (ages 18+ years) visiting an academic Level 1 trauma center between January 1, 2016, and December 31, 2017, who were imaged with MRCP for suspected biliary obstruction. Patients were scanned with either a four-sequence A-MRCP protocol or a conventional eight-sequence MRCP (C-MRCP) protocol. Image acquisition and MRI room time were compared. The radiology report was used to determine whether a study was limited by motion or prematurely aborted, as well as for the presence of pertinent biliary findings. Diagnostic accuracy of A-MRCP studies were compared with any available endoscopic retrograde cholangiopancreatography (ERCP) report within 30 days. Results One hundred sixteen patients met inclusion criteria; 85 were scanned with the A-MRCP protocol (45.9% male, mean 57.4 years) and 31 with the C-MRCP protocol (38.7% male, mean 58.3 years). Mean image acquisition time and MRI room time for the A-MRCP protocol were significantly lower compared to those for the C-MRCP protocol (16 and 34 min vs. 42 and 61 min, both p < 0.0001). Choledocholithiasis was seen in 23.5% of A-MRCP cases and 19.4% of C-MRCP cases. Non-biliary findings were common in both cohorts, comprising 56.5% of A-MRCP cases and 41.9% of C-MRCP cases. 44.7% of A-MRCP patients received subsequent (diagnostic or therapeutic) ERCP (mean follow-up time 3 days), in which A-MRCP accurately identified choledocholithiasis in 86.8% of cases, with sensitivity of 85%, specificity of 88.9%, positive predictive value (PPV) of 89.5%, and negative predictive value (NPV) of 84.2%. In comparison, 38.7% of C-MRCP patients underwent ERCP (mean follow-up of 2.3 days) with an accuracy of 91.7%, sensitivity of 80%, specificity of 100%, PPV of 100%, and NPV of 87.5%. Only 4.7% of A-MRCP exams demonstrated motion artifact vs. 12.9% of C-MRCP exams. One study was prematurely aborted due to patient discomfort in the A-MRCP cohort while no studies were terminated in the C-MRCP cohort. Conclusion An abbreviated MRCP protocol to evaluate for choledocholithiasis provides significant time savings and reduced motion artifact over the conventional MRCP protocol while providing similar diagnostic accuracy.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com

Therapeutics

Sexual Functioning in Hyperprolactinemic Patients Treated With Cabergoline or Bromocriptine Background: Elevated prolactin levels were found to be associated with impaired sexuality. Study Question: The aim of the study was to compare the impact of bromocriptine and cabergoline on sexual functioning in both genders. Study Design: The study enrolled 39 young women and 18 young men receiving bromocriptine treatment. In 19 women and 8 men, because of poor tolerance, bromocriptine was replaced with cabergoline, whereas the remaining ones continued bromocriptine treatment. Measures and Outcomes: Apart from measuring serum levels of prolactin and insulin sensitivity, at the beginning of the study and 16 weeks later, all included patients completed questionnaires evaluating female or male sexual functioning (Female Sexual Function Index; International Index of Erectile Function-15). Results: Irrespective of the gender, posttreatment prolactin levels were lower in cabergoline-treated patients than in bromocriptine-treated patients. Baseline sexual functioning did not differ between patients well and poorly tolerating bromocriptine treatment. Neither in men nor in women receiving bromocriptine, posttreatment sexual functioning differed from baseline one. In both genders, cabergoline improved sexual desire. Moreover, in men, the drug improved erectile and orgasmic function, whereas in women, it improved sexual arousal. All these effects correlated with the impact of this drug on prolactin levels and on insulin sensitivity. Conclusions: Cabergoline is superior to bromocriptine in affecting male and female sexual functioning and should be preferred in hyperprolactinemic men and women with sexual dysfunction.

Effect of Treating Vitamin D Deficiency in Uncontrolled Type 2 Diabetes: A Randomized, Placebo-Controlled Study Background: Literature increasingly supports the inverse relationship of vitamin D (VitD) level and type 2 diabetes (T2DM). Proposed protective mechanisms of VitD include its anti-inflammatory effects, increased insulin secretion via pancreatic β-cell stimulation, and downregulation of parathyroid hormone levels. Interventional studies show mixed results of VitD therapy in prediabetic patients with VitD deficiency or diabetic patients with normal VitD levels. Study Question: Does high-dose VitD replacement improve glycemic control and microalbuminuria (MAU) in uncontrolled T2DM and concurrent VitD deficiency? Study Design: This placebo-controlled, double-blinded study randomized 30 subjects aged 30–65 years with an elevated HbA1c level of 7.5%–10% and a low total 25-hydroxyvitamin-D value of <20 ng/mL to either placebo (n = 16) or ergocalciferol 50,000 IU (n = 14) once weekly for 8 weeks then once monthly for 4 months. Measures and Outcomes: Primary outcome was difference in HbA1c from baseline to month 6 between the VitD-intervention group and the placebo-controlled group. Secondary end points were differences in total 25-hydroxyvitamin-D and MAU. Paired t tests and linear mixed-effects models were used for statistical analysis. Results: No significant differences were seen in HbA1c or MAU between baseline versus postintervention visits within the placebo group (HbA1c: 8.4% ± 0.2 vs. 8.1% ± 0.3, P = 0.088; MAU: 94.1 mg/g ± 43.9 vs. 45.9 mg/g ± 20.2, P = 0.152) and the intervention group (HbA1c: 8.8% ± 0.3 vs. 8.7% ± 0.4, P = 0.692; MAU: 167.8 mg/g ± 70.1 vs. 108.5 mg/g ± 39.9, P = 0.356). The difference between placebo-slope and intervention-slope was nonsignificant for MAU (β = −0.1 mg/g ± 0.4, P = 0.835) but was significant for total 25-hydroxyvitamin-D (β = 11.7 ng/mL ± 2.5, P ≤ 0.001). Greater HbA1c reduction occurred unexpectedly in the placebo group ( JOURNAL/ajthe/04.02/00045391-201908000-00002/math_2MM1/v/2019-07-21T181442Z/r/image-tiff = −0.4% ± 0.2) than in the intervention group ( JOURNAL/ajthe/04.02/00045391-201908000-00002/math_2MM2/v/2019-07-21T181442Z/r/image-tiff = −0.2% ± 0.4), although the difference in slopes was not significant (β = 0.2% ± 0.4, P = 0.640). Conclusions: Our proof-of-concept study found no benefit of high-dose VitD therapy in glycemic control and MAU in uncontrolled T2DM and VitD deficiency. Post hoc analyses raise concerns for high-dose VitD therapy to delay glycemic improvement. Large-scale interventional trials are much needed in this patient population to substantiate our findings and elucidate VitD's mechanisms on glucose metabolism.

Therapeutic Outcome of Achalasia Based on High-Resolution Manometry: A Korean Multicenter Study Background: Because achalasia subtype is associated with therapeutic response, it is possible that regional differences in subtype distribution could lead to differences in therapeutic outcomes. Study Question: We aimed to evaluate and compare high-resolution manometry (HRM) profiles among the different subtypes of achalasia and to elucidate predictive factors associated with treatment outcomes. Study Design: Patients who were diagnosed with achalasia using HRM at 4 Korean university hospitals were retrospectively identified and analyzed. Sixty-four patients with untreated achalasia were divided into 3 subtypes using the Chicago classification system. Measures and Outcomes: Clinical characteristics, manometric features, and treatment outcomes were compared. Results: Among 64 patients diagnosed with achalasia, 31 patients were classified as type I, 27 as type II, and 6 as type III. Regarding HRM parameters, there were statistically significant differences in basal lower esophageal sphincter pressure, 4-second-integrated relaxation pressure, residual upper esophageal sphincter pressure, body amplitude, and maximal intrabolus pressure between subtypes. Regarding therapeutic outcome, type II patients (overall success rate of 80.0%) were more likely to respond than type I (55.2%) or type III (33.2%) patients. Multivariate analysis demonstrated that achalasia subtype (type I vs. III, P = 0.072; type II vs. III, P = 0.005), therapeutic modality (dilation vs. pharmacologic, P = 0.013; laparoscopic Heller's myotomy vs. pharmacologic, P = 0.006), and HRM-measured esophageal length (<27.5 vs. ≥27.5 cm, P = 0.014) are independent predictive factors for therapeutic failure. Conclusions: Patients with type II achalasia had better treatment outcomes than patients with other achalasia subtypes. Achalasia subtype, therapeutic modality, and esophageal length are independent predictive factors of therapeutic outcome.

Enhancing HIV Pre-exposure Prophylaxis Practices via an Educational Intervention Background: Pre-exposure prophylaxis (PrEP) for HIV involves using antiretroviral drugs to prevent individuals at high risk from acquiring HIV infection. Most practicing primary care providers believe PrEP to be safe and effective, but less than half have prescribed or referred for PrEP. Attitudes and prescribing patterns among house officers have not been well described previously. Study Question: Can an educational intervention enhance HIV PrEP practices among internal medicine house officers? Study Design: This study relied on a pretest/posttest design. All categorical trainees at a medium-sized internal medicine program were offered a baseline survey to assess their knowledge on PrEP. This was followed by a PrEP-focused educational intervention and a postintervention survey. Measures and Outcomes: Likert scales captured perceptions regarding safety, effectiveness, barriers, factors that would promote PrEP use, potential side effects, impact on risk-taking behavior, and provider comfort level in assessing behavioral risks and in PrEP prescribing. Data were analyzed using descriptive statistics, Wilcoxon signed rank test, and the Kruskal–Wallis test. Significance was accepted for P < 0.05. Results: Forty-eight (100%) trainees participated in the educational session, 45 (94%) in a preintervention survey, and 36 (75%) in a postintervention survey. Before PrEP training, 22% of respondents were unaware of PrEP, 78% believed PrEP was effective, 66% believed PrEP was safe, 62% had fair or poor awareness of side effects; 18% of residents had referred for or prescribed PrEP, and 31% believed they were likely to prescribe PrEP in the next 6 months. After the intervention, 94% of trainees believed PrEP was effective (P < 0.001), 92% believed PrEP was safe (P < 0.001), and two-thirds believed they were likely to prescribe PrEP in the next 6 months. Conclusions: Brief, focused training on HIV prevention promotes awareness, acceptance, and likelihood of prescribing PrEP by internal medicine trainees.

Prevention of Recurrent Ventricular Tachycardia in Patients With Implantable Cardioverter Defibrillators—A Network Meta-analysis Background: The optimal management for the prevention of recurrent ventricular tachycardia in patients with implantable cardioverter-defibrillators (ICDs) offers a challenge with no set guidelines regarding which therapy offers a best safety and efficacy profile. Study Question: Which therapeutic strategy, among antiarrhythmic drugs and catheter ablation (CA), offers the most effective and safe approach in patients with ICDs? Data Sources: Randomized controlled trials (RCTs) comparing the efficacy and safety of antiarrhythmic drugs or CA against a placebo group. RCTs were identified from a comprehensive search in PubMed, Embase, and Cochrane library. Study Design: Our outcomes of interest were reductions in appropriate ICD shocks, inappropriate ICD shocks, and overall mortality. We used the event rates in both groups, and then using a frequentist approach employing a graph theory methodology, we constructed a network meta-analysis model. Results: Fourteen RCTs with 3815 participants and 6 different interventions treatments were included in our network meta-analysis. The most effective treatment for the prevention of recurrent ventricular tachycardia after ICD is amiodarone followed by CA. Amiodarone is most effective in the reduction of appropriate and inappropriate ICD shocks with an odds ratio (OR) of 0.29 [95% confidence interval (CI), 0.11–0.74] and 0.15 (95% CI, 0.04–0.60), respectively. CA was effective in the reduction of appropriate ICD shocks (OR, 0.41; 95% CI, 0.20–0.87), whereas sotalol was effective in the reduction of inappropriate ICD shocks (OR, 0.46; 95% CI, 0.22–0.95). There was no significant reduction in the overall mortality from any therapy. There was a trend of increased mortality associated with amiodarone therapy (OR, 2.40; 95% CI, 0.92–6.26). Conclusions: Amiodarone remains the most efficacious therapy for the reduction of appropriate and inappropriate shocks in patients with ICD. No therapy resulted in mortality reduction, but amiodarone showed a trend toward increased mortality.

Fingolimod-Associated Intracerebral Lymphoproliferative Disorder Most epidemiological studies indicate that incidence of cancer in multiple sclerosis patients is lower than general population. However these studies were performed prior to the emergence of disease-modifying therapies (DMTs). The incidence of cancer may be influenced by newer generation DMTs which are immunomodulatory or immunosuppressant. We describe an atypical case of intracerebral plasmacytic lymphoproliferative disorder in a 47 years old patient on fingolimod. As worldwide usage of oral and infusion DMTs increases, heightened clinical suspicion and early recognition of these serious adverse events remain crucial.

Intravenous Immunoglobulin and Methylprednisolone for Clozapine-Associated Perimyocarditis Clinical Features: Cardiotoxicity is a rare but serious side effect of clozapine. We present a case of a psychiatric patient on chronic clozapine 75 mg daily, who presented with congestive heart failure secondary to the cardiotoxic effects of the psychiatric medication. Therapeutic Challenge: Conventional heart failure treatment failed to improve symptoms. Solution: A course of 40 mg of intravenous immunoglobulin and 125 mg of steroids was implemented, after which the patient made a full recovery. We hope to raise awareness of concurrent clozapine-induced pericarditis and myocarditis and propose a role of intravenous immunoglobulin and steroids in the treatment of drug-induced cardiomyopathy.

Intravenous Lidocaine for Intractable Renal Colic Unresponsive to Standard Therapy Clinical Features: Renal colic is defined as a flank pain radiating to the groin caused by kidney stones in the ureter (urolithiasis). Renal colic is a frequent cause of Emergency Department visits. Most renal colic cases present as acute distress and severe back and/or abdominal pain that require prompt treatment with analgesics. Therapeutic Challenge: Nonsteroidal anti-inflammatory drugs and opioids are traditionally used for renal colic in the Emergency Department. This trend of practice is based on clinical experience and expert opinion. Consensus guidelines that provide evidence-based approach for the management of renal colic are limited. One consensus guideline from Europe provides a systematic approach for the management of pain with the use of nonsteroidal anti-inflammatory drugss and opioids. However, no guidance is provided on how to manage patients who do not respond to these agents. Solution: Intravenous lidocaine 120 mg in 100 mL normal saline was infused over 10 minutes for pain management for intractable renal colic unresponsive to standard therapy. Three minutes after initiation of lidocaine infusion, the patient reported numeric pain rating scale 1/10. At 5 minutes, the reported numeric pain rating scale was 0/10 and remained for 60 minutes after initiation of lidocaine infusion. No adverse events were reported during or after the infusion, and no subsequent analgesia was required.

Intravenous Fluid Therapy in Hospitalized Patients No abstract available

Anticoagulation in Patients Prone to Falling No abstract available

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com

Obstetrical & Gynecological Survey

Interventions to Prevent Perinatal Depression: Evidence Report and Systematic Review for the US Preventive Services Task Force (Abstracted from JAMA 2019;321(6):588–601) Perinatal depression is a common condition that was estimated in 2012 to affect more than 180,000 new mothers (11.5%) annually in the United States and that can have serious impact on mother and infant well-being. Numerous interventions have been proposed to prevent perinatal depression, but there is no commonly agreed-on prevention method, creating a scenario with substantial variation in clinical practice.

Pregnancy Outcome After First Trimester Exposure to Ionizing Radiations (Abstracted from Eur J Obstet Gynecol Repr Biol 2019;232:18–21) Exposure to ionizing radiation during pregnancy induces anxiety for both pregnant patients and their practicing physicians. The effects of radiation exposures can be classified as deterministic and stochastic.

Prepregnancy and Early Pregnancy Calcium Supplementation Among Women at High Risk of Pre-eclampsia: A Multicentre, Double-blind, Randomised, Placebo-Controlled Trial (Abstracted from Lancet 2019;393:330–339) Hypertension complicates 5% of all pregnancies and 11% of first pregnancies, and half of these cases are associated with preeclampsia (gestational hypertension plus proteinuria). Hypertensive disorders of pregnancy are the direct cause of death of approximately 30,000 women annually, or approximately 14% of maternal deaths, most of which occur in low-income countries.

The Frequency of Intrapartum Caesarean Section Use With the WHO Partograph Versus Zhang's Guideline in the Labour Progression Study (LaPS): A Multicentre, Cluster-Randomised Controlled Trial (Abstracted from Lancet 2019;393:340–348) The rate of cesarean sections is increasing worldwide and is a great concern because of its association with adverse outcomes for mothers and babies, the more than 50% risk for a subsequent cesarean section, and the increase in costs of labor care. Assessment and identification of labor progression and prolonged labor, denoted as true labor dystocia and often caused by inadequate contractions or obstructed labor, have profound effects on labor management and intrapartum cesarean section (ICS) use, because labor dystocia is the main indication for an ICS.

Hospital Variation in Utilization and Success of Trial of Labor After a Prior Cesarean (Abstracted from Am J Obstet Gynecol 2019;220:98.e1–98.e14) The rate of cesarean delivery in the United States has increased from 20.7% in 1996 to 31.9% in 2016. Cesarean delivery places the mother and fetus at increased risk of morbidities such as surgical injuries, maternal thromboembolic and anesthesia complications, and neonatal respiratory distress.

Association Among County-Level Economic Factors, Clinician Supply, Metropolitan or Rural Location, and Neonatal Abstinence Syndrome (Abstracted from JAMA 2019;321(4):385–393) Neonatal abstinence syndrome (NAS) has increased over the last 2 decades, likely related to the increase in opioid use in the United States from 1999 to 2014. The increased use of opioid analgesics, heroin, and fentanyl, associated with increased opioid overdose death rates, has severely impacted poor, rural counties, where residents are at risk because they have poor access to health care and other economic and social opportunities.

Non-invasive Prenatal Sequencing for Multiple Mendelian Monogenic Disorders Using Circulating Cell-free Fetal DNA (Abstracted from Nat Med 2019;25:439–447) Noninvasive prenatal screening has focused on the detection of chromosomal abnormalities in the fetus. At present, screening for many dominant monogenic disorders associated with de novo mutations is not available, despite their relatively high incidence.

Advanced Paternal Age, Infertility, and Reproductive Risks: A Review of the Literature (Abstracted from Prenat Diagn 2019;39:81–87) Advanced paternal age (APA) is associated with infertility and other reproductive risks. Studies looking at APA and outcomes have used different paternal age cutoffs, which has complicated systematic evaluations of reproductive risk associated with paternal aging.

Vaginoscopy Against Standard Treatment (VAST): A Randomised Controlled Trial (Abstracted from BJOG 2019;126:891–899) Hysteroscopy is one of the most commonly used tests in gynecology. It is used in the diagnosis of abnormal bleeding, reproductive problems, and endometrial cancer.

Gaining the Patient Perspective on Pelvic Floor Disorders' Surgical Adverse Events (Abstracted from Am J Obstet Gynecol 2019;220:185.e1–185.e10) Surgical adverse events (AEs) following urogynecological surgery are common. The incidence of any AEs in surgical studies ranges from 30% to 76%, and serious AEs range from 3% to 17%.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com

Otology & Neurotology

Density of Macrophages Immunostained With Anti-Iba1 Antibody in the Vestibular Endorgans After Cochlear Implantation in the Human Hypothesis: Cochlear implantation may result in an increase in the density of macrophages in vestibular endorgans in the human. Background: Vestibular symptoms are a common complication of cochlear implantation. In a previous study, we demonstrated histological evidence of a foreign-body response caused by silicon and platinum in the human cochlea following cochlear implantation. The objective of the current study was to seek evidence of a possible immune response in vestibular endorgans after cochlear implantation. Methods: The density of macrophages immunostained with anti-Iba1 antibody in the vestibular endorgans (lateral and posterior semicircular canals, utricle and saccule) in 10 human subjects who had undergone unilateral cochlear implantation was studied by light microscopy. The densities of macrophages in the neuroepithelium, subepithelial stroma, and among dendritic processes in the mid-stromal zone in four vestibular endorgans in the implanted and the opposite unimplanted ears were compared. The distributions of macrophage morphology (amoeboid, transitional and ramified) were also compared. Results: The densities of macrophages in implanted ears in four vestibular endorgans were significantly greater than that in opposite unimplanted ears except in the subepithelial zone of the utricle and posterior semicircular canal. In contrast to the neuroepithelium, the subepithelial distribution of amoeboid macrophages in implanted ears was significantly less than in unimplanted ears. Conclusion: An increase in the density of macrophages in four vestibular endorgans after implantation was demonstrated. The transition among phenotype of macrophages suggested possible migration of amoeboid macrophages from the subepithelial stroma into the neuroepithelium. Address correspondence and reprint requests to Joseph B. Nadol Jr, M.D., Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, 243 Charles Street, Boston, MA 02114; E-mail: joseph_nadol@meei.harvard.edu This work was supported by grants #U24-DC013983 and R01-DC000152-34 from the National Institute of Deafness and Other Communication Disorders (NIDCD). The authors disclose no conflicts of interest. Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

Vestibular Schwannoma Tumor Size Is Associated With Acute Vestibular Symptoms After Gamma Knife Therapy Objective: To assess how pretreatment vestibular schwannoma (VS) tumor characteristics are associated with vestibular symptoms after gamma knife (GK) surgery. Study Design: Retrospective chart review of patients undergoing GK treatment for VS at our institution from 2005 to 2018. Setting: Academic tertiary referral center. Patients: Patients receiving primary GK surgery for vestibular schwannomas with at least 6 months of follow up. Patients with neurofibromatosis 2 or previous surgery were excluded. Main Outcome Measures: The presence of posttreatment vestibular symptoms within 6 months after GK. Clinical records were assessed for pretreatment tumor, patient, and treatment characteristics that impacted posttreatment symptoms. Results: All patients received radiation doses between 12 and 13 Gy. Of 115 patients, the average age was 60. Thirty-seven (32%) patients developed vestibular symptoms within 6 months post-GK, and 18 patients were referred for vestibular rehabilitation. Ten of 13 patients undergoing vestibular rehabilitation reported improvement. Overall, 112 patients had tumor measurements. Pretreatment tumors were significantly smaller for patients with acute vestibular symptoms (mean 1.43 cm versus 1.71 cm, p = 0.007). On multivariate analysis, smaller tumor size (p = 0.009, odds ratio [OR] = 0.29, 95% confidence interval [CI] [0.12–0.73]) was significantly associated with vestibular symptoms within 6 months of GK. Patients with tumors less than 1.6 cm were more likely to receive referrals for vestibular rehabilitation within 6 months posttreatment (25% versus 9.4%, p = 0.026, OR = 3.22, 95% CI [1.00, 11.32]). Conclusions: Smaller vestibular schwannomas were significantly associated with higher rates of post-GK vestibular symptoms. Pretreatment tumor size may be used to counsel patients on the likelihood of post-GK vestibular symptoms and vestibular rehabilitation. Address correspondence and reprint requests to Michael J. Ruckenstein, M.D., M.Sc., Department of Otorhinolaryngology, 3400 Civic Center Blvd, South Pavilion 3rd Floor, Philadelphia, PA 19104; E-mail: michael.ruckenstein@uphs.upenn.edu This work was not funded. Disclosures: J.A.B. is the owner of MobileOptx, LLC and was a consultant for TympBio. M.A.B. received honoraria from Varian. There are no conflicts of interest. Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

Hearing and Quality of Life Over Time in Vestibular Schwannoma Patients: Observation Compared to Stereotactic Radiosurgery Objective: To examine quality of life changes for patients with vestibular schwannoma (VS) undergoing observation or stereotactic radiosurgery (SRS). Study Design: Retrospective review. Setting: Academic medical center. Patients: Patients with VS who underwent observation or SRS and had at least two audiograms and Penn Acoustic Neuroma Quality of Life (PANQOL) surveys, a quality of life survey for patients with VS. Interventions: SRS or observation. Main Outcome Measures: Pure-tone average (PTA), speech discrimination score (SDS), PANQOL score; controlling for tumor size, baseline hearing, and other factors. Results: One hundred twenty-three patients met inclusion criteria: 89 underwent observation and 34 SRS. There was no significant difference in the rate of decline measured by PTA (PTA worsened at a rate of 0.25 dB/yr more in the observation group compared with the SRS group, p = 0.77) and SDS (SDS worsened at a rate of 2.1%/yr more in the SRS group compared with the observation group, p = 0.82). Kaplan–Meier analysis demonstrated the SRS group had a higher probability to progress to class D hearing over observation (hazard ratio 7.1, p = 0.005). The rate of change of the SRS PANQOL scores was significantly improved in the total (p = 0.005) and hearing (p = 0.04) domain score compared with observation. However, both groups regress to a similar PANQOL total and hearing domain score over time. Conclusion: PANQOL scores were higher at baseline in the observation group than in the SRS group. However, over time, PANQOL scores in the observation group decreased while PANQOL scores in the SRS group increased, resulting in PANQOL scores that were equivalent by the end of follow-up. Address correspondence and reprint requests to Lauren E. Miller, M.D., M.B.A., Massachusetts Eye and Ear Infirmary, Harvard Medical School, 243 Charles Street, Boston, MA 02114; E-mail: Lauren_miller@meei.harvard.edu The Institutional Review Board at the Hospital of the University of Pennsylvania approved this study (Protocol 814830). The authors disclose no conflicts of interest. Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

Incidence and Risk of Various Disorders of the External Ear in Patients With Hearing Aids Treated in ENT Practices in Germany Objective: The aim of the study was to investigate the relationship between the presence of a hearing aid (HA) and the occurrence of various disorders of the external ear, using data from ear, nose, and throat (ENT) practices in Germany from a nationwide, representative practice database. Methods: In the period between 2012 and 2016, the incidences of disorders of the external ear (ICD-10 groups H60 and H61) in patients with HA prescriptions were compared retrospectively with a control group without HA prescriptions (1:1 matching). Results: A total of 20,127 patients with HA prescriptions were compared with 20,127 controls. The highest 12-month incidences (HA vs. controls) were determined for "Impacted cerumen" (H61.2) (16.5% vs. 4.2%), "Unspecified otitis externa" (H60.9) (2.6% vs. 1.2%) and "Acute noninfective otitis externa" (H60.5) (2.3% vs. 0.7%). The most significant risk increases for HA wearers were found for "Abscess of external ear" (H60.0, OR 10.03), "Other otitis externa" (H60.8, OR 6.00), and "Impacted cerumen" (H61.2, OR 4.55). A smaller risk increase was found for "Cholesteatoma of external ear" (H60.4, OR 2.26), among others. Conclusion: In HA wearers, the risk of developing almost all of the diagnoses reviewed is significantly increased, especially for external auditory canal (EAC) furuncle, chronic otitis externa, and impacted cerumen. This study provides the first epidemiological evidence for HA as a risk factor for the rare EAC cholesteatoma. Address correspondence and reprint requests to Karel Kostev, Ph.D., D.M.Sc., Epidemiology IQVIA, Unterschweinstiege 2-14, 60549 Frankfurt am Main, Germany; E-mail: kkostev@de.imshealth.com Compliance with ethical guidelines: Under certain conditions, German law permits the use of anonymized electronic medical data for research purposes. According to this legislation, this type of observational study without identifiable patient data does not require consent or an ethics committee vote. The authors did not have access to identifiable patient data at any time during the study. There are no conflicts of interest. Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

The Influence of Metabolic Syndrome on the Prognosis of Idiopathic Sudden Sensorineural Hearing Loss Objectives: We aimed to verify the hypothesis that metabolic syndrome (MetS) and its components affect the prognosis of idiopathic sudden sensorineural hearing loss (ISNNHL). Study Design: A retrospective cohort study. Setting: Tertiary otology referral center. Patients: We divided patients who were diagnosed with ISSNHL between January 2015 and January 2018 into a MetS group and a Non-MetS group according to the diagnostic criteria of MetS. Interventions: We diagnosed ISSNHL patients by using pure-tone audiometry and treated them with oral steroids, blood flow promoting agents, and hyperbaric oxygen therapy. Main Outcome Measures: We used multivariate logistic analysis to identify prognostic factors of ISSNHL. Results: The MetS group comprised 94 patients, and the Non-MetS group comprised 162 subjects. Despite the rate of hypertension, diabetes mellitus, hyperlipidemia, and BMI, no significant difference was observed between the two groups (p > 0.05). The rates of complete recovery and partial recovery of the MetS group were significantly lower than those of the Non-MetS group (p < 0.05). According to the multivariate analysis, MetS was significantly correlated with a poor prognosis (OR = 2.912, p = 0.008), and the OR increased with an increase in the number of MetS components. Late onset of treatment, high initial hearing threshold, and presence of diabetes mellitus and hyperlipidemia were associated with a poor prognosis (p < 0.05). Conclusions: The presence of MetS may negatively affect the recovery of Chinese patients with ISSNHL, and the prognosis was poorer with an increase in the number of MetS components. Early onset of treatment, low initial hearing threshold and absence of diabetes mellitus, and hyperlipidemia are associated with favorable hearing recovery. Address correspondence and reprint requests to Hong Sun, M.D., Ph.D., Department of Otolaryngology Head and Neck Surgery, Xiangya Hospital of Central South University, Xiangya Road 87, Changsha 410008, Hunan, China; E-mail: shjhaj@126.com Data collection: Q.J. and S.X. Data analysis and draft writing: Y.Z. Technical and material support: X.W. and Y.F. Study design and supervision: H.S. Research was funded by the National Key Basic Research Program of China (No. 2014CB943003), Natural Science Foundation of Hunan Province (No. 2018JJ3842), and the Fundamental Research Funds for the Central Universities of Central South University (No. 2017zzts236). The authors disclose no conflicts of interest. Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

Speech Perception Growth Patterns in Prelingual Deaf Children With Bilateral Sequential Cochlear Implantation Objective: To evaluate speech perception following the first (CI-1) and second (CI-2) cochlear implantation (CI) in children with sequential bilateral CI. Study Design: Retrospective. Patients: Seventy children with follow-up for 60 months post CI-1 and 36 months post CI-2. Main Outcome Measures: Word recognition score (WRS) was the main outcome. WRSs were compared by age at CI operation (group A ≤ 3.5 yr, B 3.6–8.6, for CI-1; group I ≤ 3.5 yr, II 3.6–7.0, III 7.1–13, IV > 13, for CI-2). Results: For CI-1, the WRS of group A exceeded 80% at 24 months post procedure, earlier than group B (54 mo). Group A also had a shorter period of CI-1 use up to the WRS plateau than group B. CI-2 showed an initial burst of WRS growth much earlier than CI-1. This initial burst was most robust within 3 months in group II, but modest in group IV. The periods of CI-2 use (11–17 mo) up to the WRS plateau were much shorter than CI-1 (40–64 mo). Group I did not show the best WRS at 1 month post CI but later exceeded the other groups. Conclusion: Children received an immediate benefit by a burst of WRS growth from CI-2 earlier than CI-1, even within 3 months, suggesting that CI-1 gets the auditory cortex ready to foster speech processing from CI-2. The CI-2 performance depends on age at CI-2 implantation and on CI-1 performance. Our current findings will be relevant for clinicians who are counselling parents on CI-2 surgery. Address correspondence and reprint requests to Hong Ju Park, M.D., Ph.D., Department of Otorhinolaryngology-Head and Neck Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Republic of Korea; E-mail: dzness@hotmail.com The authors disclose no conflicts of interest. Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

Long-term outcomes of bone conduction hearing implants in patients with bilateral microtia-atresia Objectives: To evaluate the long-term outcomes of three different types of bone conduction hearing implants (BCHI)—BAHA, Ponto, and Bonebridge—in Mandarin-speaking patients with bilateral microtia-atresia. Methods: This cohort study enrolled 59 patients affected by bilateral microtia-atresia, with an upper bone conduction threshold limit of 30 dB HL at frequencies of 0.5 to 4 kHz. All subjects underwent unilateral BCHI surgery, including 26 (18 males, 8 females, of mean age 8.7 ± 1.9 yr) implanted with BAHA devices; 10 (7 males, 3 females, of mean age 11.7 ± 2.8 yr) implanted with Ponto devices; and 23 (14 males, 9 females, of mean age 9.0 ± 1.8 yr) implanted with Bonebridge devices. The main outcome measures included long-term audiological benefits, patient satisfaction, and complications. Each subject acted as his or her own control. Results: Two years after BCHI surgery, the mean hearing thresholds in the BAHA, Ponto, and Bonebridge groups had improved to 22.6 ± 1.6 dB HL, 21.6 ± 1.2 dB HL, and 22.5 ± 1.5 dB HL, respectively. The mean percentages of subjects in these three groups recognizing speech at 65 dB SPL under quiet conditions were 97.7 ± 4.2%, 96.3 ± 1.1%, and 94.4 ± 9.4%, respectively, whereas the mean percentages recognizing speech under noise conditions (signal:noise ratio +5) were 87.0 ± 1.8%, 89.3 ± 9.3%, and 85.3 ± 4.7%, respectively. Questionnaires revealed patients' benefits and satisfaction with this surgery. Three (11.5%) of 26 patients in the BAHA group and 1 (10%) of 10 in the Ponto group experienced skin irritation, but all recovered after local treatment. Five (19.2%) patients in the BAHA group and two (20%) in the Ponto experienced abutment extrusion about 6 months postoperatively, with all achieving good results after revision surgery to replace the abutment. One (3.8%) patient in the BAHA group experienced local chronic inflammation and underwent surgery to replace the BAHA with a Bonebridge implant. One (4.3%) patient in the Bonebridge group developed a local infection 3 months postoperatively and underwent implant removal. Conclusions: All three BCHIs were well tolerated after long-term follow-up, and all improved audiometric thresholds and the intelligibility of speech in the presence of both quiet and noise. These implants should be considered valid and safe options for the functional rehabilitation of patients with bilateral microtia-atresia. Address correspondence and reprint requests to Xiaowei Chen, M.D., Department of Otolaryngology, Peking Union Medical College Hospital, #1 shuaifuyuan, Beijing 100730, China; E-mail: chenxw_pumch@163.com This work was supported by grant to X.C. from the General Programs of National Natural Science Foundation of China (81271053) and The National Key Research and Development Program of China (2016YFC0901501). The authors have received no payment in the preparation of this manuscript. The authors alone are responsible for the content and writing of this article. X.C. acted as head surgeon for the BCHIs performed in this study and collected data. X.F. analyzed data, composed the manuscript, and participated in some of the operations as an assistant. T.Y., X.N., Y.W., and Y.F. participated in some of the operations as assistants, and collected and analyzed data. All authors read and approved the final manuscript. The authors disclose no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (http://journals.lww.com/otology-neurotology). This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc-nd/4.0 Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

Anatomical Correlates and Surgical Considerations for Localized Therapeutic Hypothermia Application in Cochlear Implantation Surgery Hypothesis: Application of localized, mild therapeutic hypothermia during cochlear implantation (CI) surgery is feasible for residual hearing preservation. Background: CI surgery often results in a loss of residual hearing. In preclinical studies, local application of controlled, mild therapeutic hypothermia has shown promising results as a hearing preservation strategy. This study investigated a suitable surgical approach to deliver local hypothermia in patients utilizing anatomical and radiologic measurements and experimental measurements from cadaveric human temporal bones. Methods: Ten human cadaveric temporal bones were scanned with micro-computed tomography and anatomical features and measurements predicting round window (RW) visibility were characterized. For each bone, the standard facial recess and myringotomy approaches for delivery of hypothermia were developed. The St. Thomas Hospital (STH) classification was used to record degree of RW visibility with and without placement of custom hypothermia probe. Therapeutic hypothermia was delivered through both approaches and temperatures recorded at the RW, RW niche, over the lateral semicircular canal and the supero-lateral mastoid edge. Results: The average facial recess area was 13.87 ± 5.52 mm2. The introduction of the cooling probe through either approach did not impede visualization of the RW or cochleostomy as determined by STH grading. The average temperatures at RW using the FR approach reduced by 4.57 ± 1.68 °C for RW, while using the myringotomy approach reduced by 4.11 ± 0.98 °C for RW. Conclusion: Local application of therapeutic hypothermia is clinically feasible both through the facial recess and myringotomy approaches without limiting optimal surgical visualization. Address correspondence and reprint requests to Suhrud M. Rajguru, Ph.D., University of Miami Ear Institute, 1095 NW 14 Terrance, Lois Pope Life Center, Room 4-25, Miami, Florida 33134; E-mail: s.rajguru@miami.edu E.P. and A.V.E. have equal contribution. This work was supported by a Research Grant from Cochlear, R01 DC01379801A1 and a pilot award from National Center For Advancing Translational Sciences of the National Institutes of Health under Award Number UL1TR002736, Miami Clinical and Translational Science Institute. S.M.R. and C.K. are named inventors on intellectual property related to the design of hypothermia system and probe discussed here. The authors declare no competing financial interests related to the findings presented. This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc-nd/4.0 Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

Evaluation of the Effect of Diclofenac Sodium and 5-Fluourasil in a 3D Cholesteatoma Cell Culture Model Introduction: Middle ear cholesteatoma is a benign disease with invasive and destructive clinical behaviors. It increases the rate of both chronic otitis media complications and revision surgeries. The most effective treatment of middle ear cholesteatoma is surgical excision, and there is no medical treatment for this disease. Exploring new medical treatment options may help to create treatment alternatives instead of surgery. Materials and Methods: Required cholesteatoma tissues for cell culture were excised from 4 different participants who underwent surgery in our clinic and agreed to give tissue for the study. Cholesteatoma-derived keratinocytes and fibroblasts were cocultured in temperature-sensitive culture dishes to make a three-dimensional (3D) cholesteatoma model. Then, the effects of 1% and 2% diclofenac sodium on viability and cell proliferation rates were examined using WST-1 and annexin-V tests. Results: Cell viability and proliferation rates were found to be lower and apoptosis rates were higher in the diclofenac sodium group versus the negative and positive control groups. Conclusion: In this present study, we described a new 3D cholesteatoma cell culture model developed using cell sheet technology and demonstrated the efficacy of diclofenac sodium on cholesteatoma for the first time in the literature. It may be used in patients with chronic otitis media with cholesteatoma, but further studies investigating ototoxic and neurotoxic effects of this molecule are needed. Address correspondence and reprint requests to Ahmet Kara, Sakarya University Training and Research Hospital, 54000 Korucuk, Sakarya, Turkey. E-mail: doktor.kbb@hotmail.com Funding: This study has been funded by Turkey Scientific and Technological Research Center (project number: 216S961) (TUBITAK). Date of presentation at scientific meeting: AAO-HNSF Annual Meeting & OTO Experience, 7–10.10.2018. The research protocol was approved by the Kocaeli University Animal Ethics Committee (KU GOKAEK 2013). The authors report no conflicts of interest Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

Hearing Preservation With the Use of Flex20 and Flex24 Electrodes in Patients With Partial Deafness Objective: To evaluate the impact of electrode length on hearing preservation (HP) in Partial Deafness Treatment–Electrical Complement (PDT-EC) subjects. Study Design: Retrospective case review. Setting: Tertiary referral center. Patients: Twenty-three PDT-EC patients (with preoperative air-conduction thresholds ≤30 dB up to 500 Hz) were divided into two groups: Flex20 electrode (Med-EL GmbH, Innsbruck, Austria) (12 patients) and Flex24 electrode (Med-EL GmbH, Innsbruck, Austria) (11 patients). Interventions: All participants were subjected to minimally invasive cochlear implantation using the round window approach. Main Outcome Measure(s): Pure tone audiometry (125–8000 Hz) was performed preoperatively and at 1, 6, 12, and 24 months postoperatively. HP was established using the HEARRING group formula. Speech understanding was assessed preoperatively and at 12 and 24 months postoperatively. Results: Analysis of HP for every individual indicates that more than half the patients with Flex20 and Flex24 had complete HP at 6 months follow-up. None of the patients from either group had complete loss of hearing. At activation, average air-conduction thresholds for low frequencies (125–500 Hz) were slightly better for the short electrode (M = 29.03) than for the long (M = 39.10) but the difference was not statistically significant (p = 0.067). The effect of electrode (Flex20 versus Flex24) was not significant in terms of pure tone audiometry and speech recognition at long-term follow-up. Conclusions: In the early postoperative period, complete HP was possible in a majority of patients from both groups, but slightly better HP outcomes were achieved by Flex20. In the long term, the length of the electrodes does not affect the degree of HP or speech understanding. Address correspondence and reprint requests to Piotr H. Skarzynski, Ph.D., M.D., M.S., Mokra 17 Street, 05-830 Kajetany, Poland; E-mail: p.skarzynski@ifps.org.pl No other benefits were received. The authors disclose no conflicts of interest. Supplemental digital content is available in the text. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (http://journals.lww.com/otology-neurotology). This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc-nd/4.0 Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com